Making Guidelines Effective Takes More Than a Memo

Research has shown that from 80 to 90 percent of health care costs are directly or indirectly determined by clinical decision-making. It is clear that however a health care organization tries to "re-engineer" or to apply total quality management or continuous quality improvement, it won't achieve real control of costs until it systematically addresses clinical decision-making.

We are all trying to do the right thing clinically, but we suffer from information overload. There is simply too much published research out there for a single person to digest. It has been said that more than 30,000 medical research articles are published each month. I am an internist. I see patients in an urgent care clinic. I don't want to embarrass myself by reporting the number of articles I read and retain each and every month, but suffice it to say it is far fewer than 30,000. I often ask myself, "Could my not being aware of some of the information in all these articles lead to suboptimal medical care in certain situations?" The answer is probably yes.

So where do we go from here? We need to get relevant, important clinical information to clinicians in time for them to apply it in their treatment of patients. And I believe practice guidelines are one way — not the only way — to make sure important innovations in medical care are translated into widespread clinical practice. We may grumble about it, but where we're headed is toward on-line clinical information systems that let us summon the latest accepted clinical knowledge in "real time" — quickly enough to help us in diagnosing the patient or choosing a course of treatment. The phenomenon may not always carry the label "practice guidelines." But whatever it's called, the idea of translating innovations in medical care into widespread clinical practice has been around for centuries and will survive for centuries to come.

Why does an institution or organization choose to develop practice guidelines? Because variations in treatment may mean variations in both quality and cost, and our goal is to reduce those unexplained variations by promoting widespread adoption of practices that have been found to promote the highest quality at the most reasonable cost.

Locating guidelines

Generally speaking, finding practice guidelines is no great trick. The AMA's directory of practice parameters lists more than 1,600 sets of available guidelines, and more are being developed all the time. Because it takes many months to develop a new set of guidelines for a particular condition, it may be desirable to find an existing set to customize for use in one's own group or institution.

There are, however, a number of barriers to implementing practice guidelines. For one thing, many of us have learned the hard way that old habits die hard. Education alone usually fails to produce sustained changes in clinical practice. Almost every study I've seen suggests that relying principally on grand rounds or an educational memo to disseminate a set of practice guidelines does not lead to sustained change.

There are several implementation tactics to win allegiance for new practice guidelines, some of which risk heavy-handedness in varying degrees. They include financial incentives, administrative edicts and real-time reminders such as having case managers give information to clinicians while they are delivering care. However, one should not consider a more persuasive implementation strategy unless there is "rock solid" evidence that following a guideline will improve patient care.

Sometimes physicians complain that guidelines constitute "cookbook medicine." They misunderstand cookbooks themselves, but that may not be a point worth arguing. Instead, stress your sincere belief that your evidence-based guidelines, which draw upon the latest studies in the field, represent the best way of caring for patients. Can the objecting doctors point to methodological flaws in the studies on which the guidelines are based? If so, you're all ears. Certainly there is an art of medicine, which is very important, but it begins where the science of medicine leaves off. It is not a substitute for it.

In some cases, guidelines may be resisted because of their source. A recent study of American College of Physicians members found that the guidelines with the greatest credibility among them in a given area were ACP's own, with Blue Cross/Blue Shield guidelines way down the list. ACP guidelines won a powerful approval score of 4.2 out of a possible 5, with Blue Cross/Blue Shield guidelines posting a mere 2.1. That was especially striking because they were the same guidelines. The ACP guidelines had been developed in conjunction with the Blue Cross/Blue Shield guidelines, so their content was identical.

Right idea, wrong place

Another thing I've learned the hard way is that a guideline that is right for one area may be wrong for another. I was once involved in developing guidelines for treating patients with hip fractures, and we thought we could significantly reduce length of stay for acute care in a hospital safely if patients received physical therapy in their home at least as often as they received it in the hospital. We were working with a rural hospital back east and I got a call from one of their orthopedic surgeons. "Scott," he said, "you don't really know rural medicine all that well, do you?"

"To be honest with you," I replied, "I probably don't know it as well as I should."

"It gets very cold in the winter here, and we have a lot of farmers who live five, 10 or 15 miles apart. We don't have universally available home health services, and it's completely unrealistic to expect that with icy roads and everyone living so far apart we're going to get once- or twice-daily home physical therapy for a hip fracture patient seven days a week." One of the barriers to transporting guidelines, we discovered, is that cultures and resources are different in different parts of the country and you really have to understand the differences and go from there.

Finally, I believe a simple lack of communication within organizations prevents many practice guidelines from being effective. A few years ago I was asked to visit an organization to talk about guidelines. I crossed the country and met with the director of quality management, and I was kind of nervous. She told me her organization had 83 sets of guidelines and pathways. I said, "Wow! This is embarrassing. You guys paid my air fare, and I'm supposed to be the expert. But I'm personally working with maybe two or three."

Undaunted, I gave my presentation, and at lunch that day I sat down with the chief of surgery and the chief of medicine. "I understand you guys have 83 sets of guidelines," I said. "I didn't want to say this in my lecture, but I am working with two or three."

They looked at me and said, "We have 83 sets of guidelines? I had no idea."

Clearly there had been a disconnect between the people developing these excellent, evidence-based, scientific guidelines and the people who were supposed to be using them. Brilliant though they may have been, I doubt that those guidelines led to much improvement in actual patient care.

The author is director of health service research at Cedars-Sinai Medical Center in Los Angeles, an assistant professor of medicine at the University of California at Los Angeles School of Medicine, and a consulting medical director of Prime Health, a network of physicians and managed care organizations in southern California. This column is adapted from a presentation made at the Zitter Group's Congress on Health Outcomes and Accountability in Washington in December.